31 Jan Case 1: An 89-year-old female complains of a ‘stabbing chest pain’ and points to the area just below her scapula at the right mid-clavicular line. She states that she had an up
Case 1: An 89-year-old female complains of a "stabbing chest pain" and points to the area just below her scapula at the right mid-clavicular line. She states that she had an upper respiratory infection last week that "just seems to hang on." No other complaints.
- Use the Case Study Template to complete Download Use the Case Study Template to complete
- Be sure to include at least one reference.
- Include in-text citations as needed.
Physical Assessment
Case Study Template
Name: ________________________________________
Week of Class (1-8): ______
Body System focus area (i.e., cardiovascular): _____________________________
Case Study: (copy/paste here please)
Note: Include in-text citations as needed (author, year).
Questions (if data is unavailable, indicate “unavailable”):
1. What is the client’s chief complaint?
2. What questions would you ask the client?
· HPI (history of present illness)
· ROS (review of systems)
· Medical/Surgical/Psych History
· Family History
· Other
3. What physical examinations would you include?
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Body System |
Include? ü (yes) or – (not indicated) |
Notes |
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General survey |
ü |
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HEENT (head, eyes, ears, nose, throat/thyroid) |
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Cardiovascular |
ü |
Auscultate heart sounds (stethoscope to actual skin) |
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Peripheral Vascular |
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Breasts |
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Lymphatic |
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Pulmonary |
ü |
Auscultate lung sounds (stethoscope to actual skin) – anterior and posterior |
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Gastrointestinal/Abdominal |
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Genitourinary/Pregnancy |
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Integumentary |
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Musculoskeletal |
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Neurological |
4. What are pertinent positive physical assessment findings?
5. What are the pertinent negative physical assessment findings?
6. What are at least 3 differential diagnoses (use Up-to-Date App if needed)?
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7. What is your primary diagnosis?
8. What is your treatment plan?
· Diagnostic procedures
· Labs
· Client education (including lifestyle modifications, if applicable)
· Pharmacotherapy (including complementary and alternative therapies)
· Health promotion (preventative care, anticipatory guidance)
· Follow-Up
References
(within last 5 years, scholarly, include clinical practice guidelines if available)
APA format please, at least one reference
